Healthcare Provider Details

I. General information

NPI: 1376685685
Provider Name (Legal Business Name): HIPOLITO GALLARDO MARIANO JR. M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 E OLIVE AVE
FRESNO CA
93702-1030
US

IV. Provider business mailing address

3121 E OLIVE AVE
FRESNO CA
93702-1030
US

V. Phone/Fax

Practice location:
  • Phone: 559-412-4927
  • Fax: 559-493-5028
Mailing address:
  • Phone: 559-412-4927
  • Fax: 559-493-5028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA88903
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA88903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: